Courtney Ross: Good afternoon and welcome to Facebook Live with Chisholm Chisholm & Kilpatrick.

I'm Courtney Ross. I'm joined today by Alyse Galoski and Alec Saxe. Today, we're going

to be talking about diabetes. So, I want to get started just by generally talking about

what diabetes is. So, there're two types: Type 1 and Type 2. For purposes of this broadcast,

we're going to really be focused on Type 2 diabetes which is a chronic condition that

affects the body's blood glucose levels due to either insulin deficiency or being insulin

resistant. Type 1 is a similar condition but it typically develops in adolescence so you

usually have it earlier on in your life. And for VA adjudication purposes, there's actually

a distinction between Type 1 and Type 2. We're going to get to this later in the broadcast

which is to give you an example, Type 2 diabetes is a condition that VA will presume is due

to the veteran's exposure to herbicides and Agent Orange where Type 1 is not for that

same presumption. So, the severity of the condition can vary case by case. Some individuals

are able to control Type 2 diabetes with a restricted diet while other people have a

more difficult time doing that. As the condition progresses, it can become a little bit more

difficult to really control those blood glucose levels. So, for veterans who may already be

service-connected for this type of condition, it's important to kind of monitor how your

disease progresses because the more severe it gets, you may be entitled to a higher rating

from VA, which means additional compensation for that benefit. And that's kind of a good

segway into the next thing I want to talk about, which is, how VA rates Type 2 diabetes.

What they're looking at to decide what rating is appropriate for a veteran's condition.

So, Alyse, can you talk a little bit about that?

Alyse Galoski: Sure. So there are various different ratings that you could get for Type

2 diabetes. They range from a 10% rating all the way up to 100% rating and as Courtney

was touching upon it, a big factor is how you are having to control your diabetes. A

10% rating, for example, would be somebody who can control it just with a restricted

diet, whereas, 20% is someone who requires a restricted diet or they require a certain

exercise routine or they require insulin. Then we go up to 40% based on how often you

might need that insulin, if you need it more than just once a day. You may-- you're starting

to look into those higher ratings. You're also looking at some reactions that you might

have in the higher ratings. For example, if you are hypoglycemic, if you have those types

of reactions, that's when you're going to start getting into those 40%, 60%. Excuse

me, 60% ratings, 100% ratings. You can also suffer complications from your diabetes. For

example, we're going to touch upon this a little bit later but maybe if you have an

eye condition or a neuropathy condition, the rating criteria right in the criteria tells--

directs adjudicators that they are to rate those complications separately so long as

they basically come up to a compensable level. But if you have ratings, excuse me, if you

have complications rather that are not what VA would consider compensable, that may entitle

you to a 60% rating. Hospitalizations also come into effect if you are having to be hospitalized,

that might warrant a 100% rating. So these are just the factors but a very common theme

that we're seeing that Courtney touched upon is how you are actually having to control

and manage your blood sugar levels.

Courtney: Thank you, Alyse. So, I want to back up a little bit. We talked about how

VA rates diabetes once a veteran is service-connected for it. Let's back up a little bit and talk

about ways to actually get service-connection for diabetes. So, Alec, can you talk a little

bit about one way that a veteran might be able to seek.

Alec Saxe:Sure. Yes, of course. As we touched on the most prevalent way we see a

veteran becomes service-connected for diabetes-related to service is through the exposure to these

harmful chemical herbicides, specifically, Agent Orange and that would be for veterans

who serve with boots on the ground on in the inland waterways of Vietnam, specifically

between these certain dates that VA has set, January 9, 1962, and May 7, 1975. If you are

a veteran who served, again boots on the ground in the Republic of Vietnam, or in the waterways

which I'll expand on a little later, VA presumes that you are exposed to those harmful chemical

agents and if you have the diagnosis of diabetes, then you're entitled to service-connection

and disability compensation benefits for it. So, for a long time, no one really knew what

these inland waterways were up until recently really, last year the Federal Circuit in a

case called Procopio, decided that under the statute and the term of Republic of Vietnam

and what does that refer to, it's built its landmass but also a 12-nautical mile territorial

sea, seaward of the demarcation line of Vietnam which is a little technical. We have some

literature on our website and some visual representations that can kind of help you

out with that territory off the coast of Vietnam. So, Congress has essentially codified the

decision and now called the Blue Water Navy Vietnam Veterans Act. So, VA terms it if you

are a Blue Water Navy Veteran, again, who served within this 12-nautical-mile range

between the same dates, again, January 1962 and May 1975, you are entitled to that same

presumption that your fellow veterans who have boots on the ground receive. So, again,

those are the common ways this exposure to Agent Orange as a Vietnam era veteran but

in addition to that, veterans who flew on or worked on specific aircraft C-123's between

1969 and 1986, these aircraft are used to spray the actual chemical Agent Orange over

the forested areas in Vietnam during Operation Ranch Hand. So, if you were a part of that

operation or working on those aircraft, that presumption can extend to you. We have information,

again, on that on our website. So, in addition to that, we have veterans who served near

the Korean DMZ or along the DMZ between September 1967 and August 1971, actually, the Blue Water

Act recently expanded those dates as well. So, those are the dates 1967 to 1971. And

then last, we have Thailand. If you served on or near Thailand military bases between

February 1961 and May 1975, again, Agent Orange was used to spray the surrounding forested

areas in preparation for attacks from the enemy. So, there's bountiful evidence that

veterans serving in those Thailand military bases were exposed to Agent Orange and they're

presumed to have the presumption as well. So, those are all the chemical herbicides,

Agent Orange links. In addition to that, I'll just note that VA considers diabetes a chronic

disease under 38 CFR 309/7, both of them, I think. So, if you developed diabetes within

a year of your discharge, you may be entitled to service connection and compensation benefits

for that.

Courtney: Yes. We've recently done some other Facebook Live videos that specifically

discuss the Blue Water Navy Act and the recent extension of the presumption of exposure to

those veterans as well. So, you can check those out on our website as well. So, you

talked a lot about presumptive service connection, one other way that you may be able to seek

service connection for diabetes is as a secondary condition. Secondary service connection means

getting service connection for a condition that developed not as duty or service but

instead as due to a condition that you're already service-connected for. So, one of

the most common ones that we see with diabetes is the development of diabetes being caused

by sleep disorders or sleep apnea. VA and DOD, or the Department of Defense, actually

did a study that showed individuals with sleep apnea or poor sleep quality typically develop

diabetes. So, for sleep apnea, it actually increases the risk of diabetes by 78% which

is a pretty significant number. And those that have trouble sleeping had a 21% increase

in terms of a risk of developing diabetes. So, there's a significant connection there.

That's just one example. It could be possible that there's other conditions that may cause

or reach the development of diabetes as well. So, in addition to considering trying to connect

diabetes directly to the time of service or as a presumptive condition due to exposure,

you should also consider whether the condition may have developed later in life and may be

connected to a condition you're already getting service-connected benefits for from VA. Another

example is actually drugs that may be prescribed to you to treat things like high cholesterol

or a heart condition. So, if you are already service-connected for a heart condition, there

may be certain drugs that you're taking for that condition that can actually increase

the risk of diabetes as well. There's medical literature that supports the possible connection

there too. So this is just a different way that you may be able to get service-connected

from diabetes. So, just other things that you want to consider as well. A third way

which relates to secondary service connection but isn't exactly the same is actually using

obesity as an intermediate step. Alyse, can you talk a little bit about what is meant

by that?

Alyse: Sure. Just as a general matter, obesity is not actually a disability for VA

purposes. So, you cannot receive service connection for obesity; however, you can use obesity

as you had just said, Courtney, as an intermediate step to get your secondary service connection.

And this is really a hot button topic right now and the reason for that is that obesity

is very common among the veterans' population and so is diabetes. The reason for that is

that they're actually linked. If you have obesity, you are more prone to develop Type

2 diabetes and a lot of veterans do suffer from obesity due to multiple reasons, whether

they have different disabilities that preclude exercise or they're on certain medication,

or whatever it might be. So, the court has recently determined that you can't get service-connected

for obesity but you can have that linked. So, what that would mean is if you have a

condition that is service-connected that causes your obesity and then your obesity causes

diabetes, you can use that as a link to get the secondary service connection. So, for

a specific example, maybe you have a severe knee disability that prevents you from being

able to move around a lot. As a result, you have become obese, and as a result of obesity,

you have developed diabetes. So, as long as that knee condition is service-connected,

the diabetes can be service-connected. So, you can't get direct service connection

from obesity but it is a useful tool to get you service-connected for a different condition

that you might have developed.

Courtney: That's really helpful. So, something else to consider and think about if you're

suffering from diabetes and you're looking to try to get VA benefits. I just want to

pause quickly and remind our viewers that if you have any questions throughout the broadcast,

please feel free to leave the questions in the comments section. We'll do our best to

answer them as we go. So, we've talked a little bit about secondary service connection for

diabetes. So, getting benefits for diabetes as due to an already service-connected condition,

I want to switch gears now and talk about, and Alyse alluded to this a little bit in

the beginning of the broadcast, conditions that may have developed due to your diabetes.

So, these conditions you may be able to get service-connected for secondary to your diabetes

once that's service-connected. So, Alec, can you talk a little bit about what some of those

conditions are and what are the most common examples.

Alec: Sure. So, according to VA actually, diabetes is the leading cause of blindness,

end-stage renal disease, and amputation for VA patients. Some other common conditions

we see secondary to diabetes are diabetic peripheral neuropathy which is characterized

by weakness, numbness, pain from nerve damage, and typically, we see that in the extremities.

There's also renal or kidney dysfunction; diabetic retinopathy which refers to damage

to the retinas of your eyes, can be caused by diabetes as well as other eye conditions

actually such as cataracts; erectile dysfunction; cardiac conditions such as coronary artery

disease, heart attacks, strokes, and this one is always hard for me to pronounce, arteriosclerosis,

it's a build-up of fat cholesterol in your arteries so that's kind of linked with the

heart disease there, and then hypertension or high blood pressure. There are skin

conditions sometimes as well that can be secondary to diabetes.

Courtney: And so, while you may be able to only get maybe a 20% for your diabetes

under the criteria that Alyse talked about before, if you're also suffering from any

of these other conditions and you're able to establish to VA that it is due to your

diabetes, again as Alyse alluded before, you should get separate rating for each of these

conditions which should increase your overall combined rating and therefore, you're monthly

compensation that you'll get from VA. So, it's really important to kind of keep this

in mind too if you do have the condition and you start to develop some of these other conditions.

You want to make sure that you're aware of this and possibly file a claim with the VA

for them as well. So, just, generally speaking, starting with service connection, if a veteran

is seeking service connection for diabetes, what are the types of evidence that he or

she can submit to VA to help establish the service connection?

Alyse: Sure. The number one type specifically with diabetes is going to be medical evidence

whether it's from your VA treatment provider or from your own private physician. The reason

for that being that, especially rating criteria, it's very technical. It has to do with what

you're prescribed, what you're required to do. While lay evidence might be helpful in

certain situations, I think you really do want to get some of that medical evidence

for these diabetes cases because you will be running into competency issues you aren't

working with the doctor. Other types of evidence like you might attend what's called a VA exam,

we've done multiple-- or we've touched upon this in multiple Facebook Lives, VA exams

are extremely important. They will order one for you. If they order one for you, please

attend them and that's going to be another way that you'll be able to get evidence and

they will ask you questions if it's service connection. They'll probably ask you questions

about when you look into your file as to when you started to experience the diabetes. They

will also look and see if you have any exposure or any other risk factors. If it's an increased

rating claim, they'll probably be more looking at how you're treating whether you have weight

loss, if you have any hospitalizations, any other factors that are going to go into our

rating you would be entitled to.

Courtney: Yes and you could also consider getting your own outside medical opinion as

well. Sometimes VA exams come back negative and don't support your case so you can get

your own opinion, especially if you are trying to link your diabetes to an already service-connected

condition or if you're trying to link some of those conditions we talked about that's

secondary to your diabetes. For those, you're going to need a nexus medical opinion,

specifically if you're attributing those conditions to diabetes or your diabetes to the other

condition. And so, getting outside medical opinion might help you to establish that element

of service connection. The benefit of presumptive service connection, if you are a veteran who

was exposed to herbicides including Agent Orange, is that you really only need to establish

either show you fit within the presumptive exposure periods and then the diagnosis so

you don't have to include that nexus element but for the other service-connection avenues

you will. So, that's important to keep in mind too. Alec, do you have anything additional

in terms of evidence that might be helpful?

Alec: No. I just want to echo that diabetes is a more specialized condition as we say

it's really not capable of lay observation. So, it's not like an orthopedic condition

or your knee hurts, something that happens where residuals from a gunshot wound that

caused your knee to hurt. You can't really observe that. So, that's why you need a statement

from the doctor whether a VA doctor or a private physician as we noted and that nexus to either

another service-connected condition or service in general. So, I think that kind of hits

on the key point.

Courtney: Yes. I think that's a great transition to final thoughts. Alyse, do you have anything

to add in terms of final thoughts.

Alyse: Yes, I would say that diabetes is unique, the rating criteria in that they do

specifically direct the adjudicators to separately rate any complications that you might have;

however, I wouldn't just totally rely on that to assume that they will automatically separately

rate your conditions. So, what that means is I would work with your attorney or your

VSO rep and figure out how you want to file claims for those conditions that are secondary.

It kind of just protects you because even though they are directed to do so, they might

miss it.

Courtney: All right. Well, that's all that we have for you. Thank you for joining us

on Facebook Live with Chisholm Chisholm & Kilpatrick.